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COVID-19 has disproportionately impacted African Americans. Political and social determinants of health-the impact of the environments where people play, work, and live-account for up to 80% of individual and population health risk. This article provides an overview of how historical and contemporary systemic structural violence and racist structures embedded within the political and social determinants of health have led to African Americans experiencing high rates of morbidity and mortality due to COVID-19.

Community-based interventions such as health fairs feature diagnostic and preventive services that are useful to address health disparities in underserved stakeholders. Quantitative evaluation of these events presents challenges. This study applied the contemplation stage of the Trans-Theoretical Model of Behavioral Change (TTM-C) to evaluate health disparity-focused community interventions. Most of the 412 event participants self-identified as lower socioeconomic status (54%), overweight (74%), female (74%), and African American (83%). After event participation, stakeholders demonstrated significant improvement in overall TTM-C scores based on a standard t-test, where pre-event scores (M=30.8, SD=7.0) and post-event scores (M=32.3, SD=6.9) conditions t(346)=5.167, p=.001. For health disparity-related community events, underserved African American women are most likely to recognize a specific health issue and seek ideas about how to address it during these events. This study validates TTM-C behavioral change as a novel means to evaluate community health events.

Understanding universal vulnerability as inherent in human beings raises questions about the use of differentiating and stigmatizing terms such as vulnerable populations, by which individuals are grouped together based on perceived dissimilarity, deviance, or victimhood. Understanding human vulnerability also calls into question concepts, such as individual responsibility and consent, currently relied upon to resolve ethical and legal dilemmas. When normalized, vulnerability provides a powerful and inclusive conceptual tool that can help us define individual, professional, and institutional responsibility in situations of inherent inequality, such as that of researcher/research subject or doctor/patient. An appreciation of our universal vulnerability and the limitations it entails encourages richer and more robust policies and practices than are currently afforded by referring to abstract and individualistic concepts such as autonomy, equality, or independence. In particular, recognition of universal vulnerability reveals the ways in which all human beings inexorably depend on social relationships and institutions throughout the life course.

INTRODUCTION Limited is known about prevalence and risk factors for diabetes, hypertension, and hyperlipidemia among refugees. METHODS At a refugee clinic in Buffalo, N.Y. (2004-2014), 1,570 adults were studied using multivariate logistic regression. RESULTS Prevalences of diabetes, hypertension, and hyperlipidemia were 7.8%, 24.1%, and 27.1%, respectively. Among refugees, 49.2% of diabetes and 46.7% of hypertension were uncontrolled. Obesity (odds ratio [OR]=2.49; 95% confidence interval [CI]=1.61-3.85) and length of stay (OR=1.25; 95%CI=1.16-1.35) were risk factors for diabetes. Eastern European origin (OR=4.09; 95%CI=2.00-8.38), obesity (OR=2.62; 95%CI=1.92-3.58), length of follow-up (OR=1.06; 95%CI=1.00-1.12), gender (OR=0.59; 95%CI=0.44-0.78) and tobacco use (OR=1.54; 95%CI=1.00-2.38) were associated with hypertension. Age (OR=1.02; 95%CI=1.01-1.04) was associated with hyperlipidemia. CONCLUSIONS Refugees had comparable burden of non-communicable diseases, but a greaterleast once during the study period proportion of refugees than of the U.S. population had uncontrolled conditions. Duration of follow-up, obesity, tobacco use, gender, age, and region of origin were risk factors for diagnosis. Culturally-tailored chronic disease management strategies are needed.

Almost two decades ago, the Institute of Medicine’s Clinical Research Roundtable commented on the major challenges of moving health related basic science discovery to the clinical setting. The roadblocks identified included challenges in evaluating a discovery’s application to human disease, and, if justified, getting that application out to the general population. The obstacles to achieving this translation of discovery to improvements in human health remain today and are most evident in populations at highest risk for inequitably poor health. We address four potential roadblocks which, if solved, will have a great impact on achieving health equity. They are expanding the definition of basic discovery to include all facets of health disparities science, understanding the daily factors that affect a community’s well-being, including diverse populations in clinical trials, and training the right scientists to perform the community-engaged research required to move discovery to application in the community.

We conducted qualitative semi-structured telephone interviews with the directors of the 10 National Institutes of Health Centers for Population Health and Health Disparities (NIH/CPHHD) to identify factors that were associated with the sustainability of 19 interventions developed to address cancer disparities and 17 interventions developed to address cardiovascular disease disparities in the United States. Interview transcripts were analyzed using the constant comparative method of analysis to identify key themes and synthesize findings. Directors at NIH/CPHHD reported that barriers to sustainability included uncertainty about future funding and insufficient resources to build and maintain diverse stakeholder partnerships. Strategies that helped to overcome these barriers included developing and engaging community partnerships with health care systems; early pursuit of multiple funding sources; and investments in infrastructure to address the social determinants of health. Sustainability planning should be incorporated during the early stages of intervention development to facilitate maintenance of successful programs that address health disparities.

Research at safety-net hospitals may require additional planning to ensure the ethical conduct of research with vulnerable populations. This report discusses application of the principles of community-based participatory research and bioethics to establish a research partnership with a safety-net hospital in the southern U.S.

OBJECTIVES: To determine the association between the Center for Disease Control and Prevention's (CDC) Social Vulnerability Index (SVI) with the risk of COVID-19-related mortality. METHODS: We merged by county CDC's SVI and the New York Times data on coronavirus cases. We estimated the association between the SVI and risk of death from COVID-19 per 100,000 people in counties with confirmed cases (n=2,755 U.S. counties) using multivariable Poisson regression. RESULTS: The adjusted risk of COVID-19-related death followed a non-linear pattern, with the lowest risk among SVIs from 0.05 to 0.55 (roughly 3.1 to 3.5/100,000 people) and highest risk corresponding to SVI=0.95 (6.5/100,000). Compared with a SVI=0.35, SVIs of 0.85 and 0.95 were associated with 2.3 (2.1, 2.5) and 3.4 (3.1, 3.7) excess deaths per 100,000, respectively. CONCLUSIONS: High social vulnerability is associated with increased risk of COVID-19-related mortality among U.S. counties with confirmed cases.

This commentary amplifies the insidious nature of the novel coronavirus (resulting in COVID19) and its ubiquitous spread, which disproportionately and adversely affect the health and well-being of people of color. The consequence is poor health outcomes and premature death. Ample previous literature documents health inequities in the morbidity and mortality statistics for Black and Brown people in the United States. Their excess deaths are due to disproportionately high rates of serious health conditions (diabetes; hypertension; asthma; and lung, kidney, and heart disease), as well as structural factors having to do with income, employment, and the built environment in which they live. The health conditions are exacerbated with ongoing societal problems and stress emerging from the country's history of dehumanizing racial inequities. Current discrimination comes most virulently in the form of systematic and institutionalized racist policies that keep racial and ethnic minorities marginalized and disempowered. Furthermore, people of color encounter the immediate external pressures of working away from home and using public transportation during the country's extraordinary ongoing lockdown, heightening the risk of exposure to the virus. Moreover, the same population is overrepresented in jails and prisons where social distancing is impossible. Any virulent virus without a vaccine is bound to become a human petri dish in which people of color in the U.S. today are caught. The war against the coronavirus for people of color is part and parcel of the war to eliminate historic inequities and to level the socioeconomic playing field. This article covers the racial/ethnic inequities in morbidity and mortality from COVID19 and the slow and untimely response by the federal government to address mediation of the spread of the virus. For people of color to transcend the coronavirus pandemic crisis there must be comprehensive access to COVID-19 testing and early, sustained, and affordable access to health care, including hospitalization. Such access will require national leadership, which seems to be in short supply.

Research demonstrates health disparities between gender-minority individuals and cisgender individuals. These disparities arise from multiple sources, including negative health care experiences. This study examines interactions between transgender and gender non-binary (TGGNB) individuals and their health care providers. We analyzed 119 participants' descriptions of positive and negative health care experiences, and what they wish providers knew about caring for TGGNB patients. Health care experiences went well when providers and staff used inclusive language, demonstrated their experience and education, and treated identity disclosure as routine. Negative interactions were characterized by misgendering, unfamiliarity with TGGNB people and health issues, and transphobic practices. Participants wished providers understood their health concerns, did not expect their patients to educate them, and created a welcoming clinical environment. Medical educators, administrators, and providers share responsibility for improving TGGNB patient experiences. Through a framework of cultural safety, we recommend several changes to ensure more equitable treatment in health care.

Background This study examines stress and stress management from the perspective of African immigrants in southwestern Pennsylvania. Our research questions explore how participants define stress, the most common causes of stress, manifestations of stress, and common strategies for stress management. Methods We conducted a descriptive, cross-sectional, qualitative study with 34 African immigrants. Data were collected via three focus groups. Qualitative data were audio-recorded, transcribed verbatim, and analyzed to identify common themes. Results Five major types of stressors included: remittances, financial and job-related challenges, children, disconnected families, and unrealized expectations. Participants reported both physical and mental manifestations of stress and used both group-based and individual-focused coping strategies. Discussion African immigrants suffer from sources of stress that are uniquely attributed to their cultural background, immigration modalities, acculturation processes, and unrealized expectations. Health care providers must be aware of these sources of stress and potential management strategies.

Problem/Condition Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States. Reporting Period 2012–2015. Description of System Self-reported data from the 2012–2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties. Results Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days. Interpretation Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary. Public Health Action Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

To determine whether enhanced primary care services delivered preferentially to high-risk patients with diabetes (HbA1c9%) can effectively reduce racial/ethnic disparities in glycemic control.This retrospective study analyzed electronic health records to examine changes in pre-vs. post-intervention disparities in HbA1c among Hispanics/Latinos relative to non-Hispanic Whites.Mean HbA1c and prevalence of poorly controlled diabetes improved in both racial/ethnic groups, but to a greater extent among Hispanics/Latinos. Mean HbA1c dropped 0.43 points further among Hispanics/Latinos than non-Hispanic Whites (95% CI, - 0.57 to - 0.29, plt;.001). The change in disparity in prevalence of poorly controlled diabetes, measured as the ratio of post-vs. pre-intervention prevalence ratios, was 0.89 (95% CI, 0.84 to 0.94, plt;.001). Both measures indicated greater reduction among Hispanics/Latinos relative to non-Hispanic Whites.Enhanced primary care services directed at high-risk patients may improve glycemic control and reduce racial/ethnic disparities in diabetes-related outcomes in medically underserved communities.

We explored the role of dietary factors, as measured by individual behaviors and neighborhood produce availability, in the relationship between food insecurity and obesity among a representative sample of Latinos in California. We utilized data from the 2012, 2013/2014 California Health Interview Survey and included Latinos aged 18-65 years and under 200% of the federal poverty line (n=5,957). We conducted logistic regressions to first estimate the association between food insecurity and obesity and then examine whether this association remained significant after adjusting for soda and fast food consumption, perceived neighborhood fresh produce environment, and covariates. Latina women, and not men, were significantly more likely to be obese if they were very food insecure (OR=1.50, 95% CI=1.03-2.19). After adjusting for diet and neighborhood variables, only neighborhood affordability of fresh produce reduced this significant association. Policy efforts to remediate obesity among food insecurity households should focus on the affordability of neighborhood fresh produce.

Problem/Condition: Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States. Reporting Period: 2012–2015. Description of System: Self-reported data from the 2012–2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties. Results: Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days. Interpretation: Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary. Public Health Action: Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

In South Los Angeles, a community-engaged research project on obesity was initiated between a translational research institute seeking to build community-based or partnered participatory research (CBPR/CPPR) capacity, and a community partner with extensive experience. This manuscript describes the partnership-building process and discusses results from a bi-directional knowledge transfer event.

Chronic kidney disease is a non-communicable disease that is now well recognized as a major source of premature morbidity and mortality. In general, racial/ethnic minorities in the United States are more likely than non-minority groups to develop end-stage renal disease (ESRD), but paradoxically most have a lower mortality risk. Unlike most minorities, dialysis patients in Puerto Rico have a mortality risk nearly 50% higher than the national average. Multiple factors such as medical conditions, socioeconomic, environmental, and health system factors can influence health outcomes for patients with ESRD. We describe one potential health system factor that may contribute to this finding, a unique interpretation and implementation of the ESRD Medicare Secondary Payer provision in the Commonwealth of Puerto Rico. We conducted a search of regulatory documents and key stakeholder interviews to help envision the potential implications of these differences for dialysis facilities, health care providers, and patients with ESRD.

Objectives. To assess the prevalence of Adverse Childhood Experiences (ACEs) and their association with behavioral health in American Indian (AI) and non-AI populations in South Dakota. Methods. We included the validated ACE questionnaire in a statewide health survey of 16,001 households. We examined the prevalence of ACEs and behavioral health conditions in AI and non-AI populations and associations between ACEs and behavioral health. Results. Compared with non-AIs, AIs displayed higher prevalence of ACEs including abuse, neglect, and household dysfunction and had a higher total number of ACEs. For AIs and non-AIs, having six or more ACEs significantly increased the odds for depression, anxiety, PTSD, severe alcohol misuse, and smoking compared with individuals with no ACEs. Conclusions. American Indians in South Dakota experience more ACEs, which may contribute to poor behavioral health. Preventing and mitigating the effects of ACEs may have a significant impact on health disparities in AI populations.

The purpose of this paper is two-fold. First, to give an overview of the size and measure trends in health inequalities in the Comoros islands (Comoros) since 1996. Second, to assess the wide differences in health and health care across rural/urban areas and islands in Comoros, by using available and comparable leading indicators, in order to promote regular monitoring of policy goals. This assessment is aimed at reducing health inequalities and providing adequate or equal access to health care between islands. Data from the Demographic and Health Survey, Multiple Indicators Cluster Surveys from 1996, 2000 and 2012, the World Health Organization, the World Bank, the African Development Bank data sources, were analyzed for a population health-oriented approach characterized by measuring health differences from the population average, taking account of the population size of the social groups on both relative and absolute scales. The results showed that there exist geographic disparities in health in Comoros, mainly in maternal and child health.

Objective. Although emerging in Western industrialized societies, limited research exists on the links between housing and health outcomes for persons living with HIV/AIDS (PLWHAs) in sub-Saharan Africa (SSA). Methods. Using survey data collected from 605 PLWHAs in the Lower Manya Krobo district of Ghana, this paper examined the effects of housing structure, arrangements, accessibility and conditions on the physical and psychological/emotional health of respondents. Results. Results indicate that housing variables have independent effects on health outcomes, controlling for socio-economic and demographic variables. Respondents living in poor housing structures and deplorable housing conditions had poorer physical and psychological health scores. Conclusion. The findings suggest that it is relevant to think about houses occupied by PLWHAs as important sources of health inequality.

To determine the association between oral health and socioeconomic position in institutionalized older women in Mexico City.A cross-sectional study was performed in two groups: high socioeconomic position (HSEP), living in a private retirement home, and low socioeconomic position (LSEP), living in a public assistance center. Oral health was determined by edentulism, oral hygiene, healthy teeth, experience of dental caries, missing and filled teeth, gingival bleeding, dental calculus, and periodontal disease. A latent class analysis (LCA) was used to classify oral health status in dentate.Included were 170 women (HSEP 54.1% and LSEP 45.8%), average age 77.3 (SD = 9.3) years. Oral health status was formed: Edentulous 32.4% HSEP and 67.6% LSEP; Class 1 Unfavorable 0% HSEP and 100% LSEP; Class2 Slightly favorable 41.2% HSEP and58.8% LSEP; and Class3 Favorable 84.6% HSEP and 15.4% LSEP. There was a statistically significant association between socioeconomic position (plt; .001) and oral health status.The oral health of women studied was not optimal. Higher socioeconomic position was associated with better oral health status.

Mainstream bioethics has dealt inadequately with issues of race, gender, and class that intersect and shape the life experiences of vulnerable populations in the U.S., such as Black women in the rural South who have faced bioethical and public health challenges throughout U.S. history. They have suffered from health disparities, challenges to their autonomy, inadequate access to quality health care, biomedical violations, and a healthcare system that has implicit bias and discrimination. Thus, we propose a framework for biomedical and behavioral researchers and organizations who seek to engage, ethically, such vulnerable communities. The goal of this Ethical Community Engagement (ECE) framework is to empower communities, respect autonomy, and address needs of populations that suffer from health disparities. The Tuskegee/Macon County Diabetes Coalition, formed to coordinate and share information promoting healthy living and habits among citizens of this area, is a demonstration of this ECE framework.

The Mississippi Gulf Coast's Vietnamese community (MSGCVC) has repeatedly experienced physical, psychological, and economic hardship from natural and man-made disasters and economic downturn. Literature suggests that economic strain is the greatest contributor to Vietnamese population vulnerability. Previous literature focused on the aftermath of Hurricane Katrina, BP Deepwater Horizon oil spill, and urban communities. A photovoice project was conducted to measure causes and consequences of vulnerability and social resiliency by identifying sources of health strengths and health risks among individuals, families, and the community through generational and cultural perspectives. Content analysis was conducted to identify themes associated with vulnerability and resiliency and were subsequently grouped into six main categories. Findings will aid others exploring innovative approaches to addressing vulnerability and resiliency in underserved communities and applying photovoice as a research tool.

Precision medicine, a revolutionary approach to disease prevention and treatment, takes into account individual differences in lifestyle, environment, and biology. Organized by the National Institutes of Health, the All of Us Research Program seeks to engage one million or more volunteers living in the U.S. to contribute their health data over many years. The program seeks to improve health outcomes, fuel the development of new treatments for disease, and catalyze a new era of evidence-based and precise preventive care and medical treatment. Although the concept of precision medicine is promising, if we are to change the treatment paradigm and ensure that the medicines and prevention strategies people are using work for them, those who have been historically underrepresented in research must be included. To accomplish this, conversations will not be easy, and it will take purposeful time and effort to build trust toward action.

Social epigenomics measures the mechanisms through which place and context change our biology. Big data science connects, analyzes, and allows inferences from previously disconnected data. Precision medicine promises individually-tailored treatments. Together, these emerging fields are changing the way we discover, decipher, and deliver new science to populations. However, differential participation in and uptake (by adopter type-from innovators to laggards) of the discovering, deciphering, and delivering of these new mechanisms may exacerbate health disparities. Innovators and early adopters are generally from higher-resourced environments. This leads to data and findings biased towards those environments. Such biased data in turn continue to be used to generate new discoveries, further obscuring potentially underrepresented populations, and creating a nearly inescapable cycle of health inequity. We argue that equitable access to representative data is of special moral (bioethical) importance, necessary to break the cycle of health inequities.

Introduction Emotional intelligence (EI) interests medical schools as a predictive factor in their graduates' clinical success. Historically black college and university (HBCU) academic health centers produce professionals to address health disparities. This preliminary study evaluated a health disparity reduction curriculum's effect on EI. Methods Thirty-one undergraduates participating in a Meharry Medical College health disparity reduction program voluntarily self-reported demographic and EI data before and after service-learning training. Results Paired sample t-test results demonstrated significant improvement in EI subscales of total score (p = .004), self-awareness (p=.001), self-confidence (p=.007), self-control (p=.041), motivation (p=.020), and social competence (p=.036). Multiple linear analyses confirmed African American race significantly predicted EI-Motivation (F [1,29] = 5.858, p =.022). Conclusions These preliminary data support a beneficial effect in African Americans of a health disparity curriculum to improve EI, particularly the relevance of race to motivation. Future research should examine EI in HBCU medical school students.

Latino agricultural workers in California are a vulnerable population at risk for many undiagnosed health concerns. Principal among them is diabetes, and the prevalence of diagnosed and undiagnosed diabetes is difficult to estimate. In a convenience sample of 579 agricultural workers recruited through the California Heat Illness Prevention Study (CHIPS), we found HbA1c levels consistent with diabetes in 54 participants, of whom 33 (61.1%) were aware of their status. We found HbA1c levels consistent with pre-diabetes in 59 participants, of whom none was aware. Results indicate a health disparity between agricultural workers and other populations in the U.S. Many are unaware of having a chronic illness and lack resources or have other barriers to manage it. Nurses, midlevel providers, and health fairs are often the first or only point of health care contact for agricultural workers and can provide valuable information, screening, and support for this vulnerable population.

Socioeconomic factors influence the prevalence of malaria infection in endemic areas. This study evaluated the socioeconomic risk factors for Plasmodium falciparum infection in primary school children in the Volta region of Ghana.This cross-sectional study involved selected primary school children from the region; questionnaires were administered, and blood samples were collected for malaria detection using a rapid diagnostic test (RDT) and microscopy.A total of 550 primary school children were enrolled in this study. The predominant occupation of the parents was trading (mothers, 334, 60.73%; fathers, 254, 46.18%) and farming (mothers, 156, 28.36%; fathers, 170, 30.91%). Three hundred and five (305; 55.45%) children tested positive for malaria with RDT and microscopy. Male sex (AOR=1.53), rural area (Afegame school) (AOR=4.01) and parental farming occupation (AOR=6.39), were independently associated with P. falciparum infection.Plasmodium falciparum infection was significantly found in children in rural areas of Ghana with low socioeconomic status in this study.

Objective: To examine systematically the literature on the effect of geographical location variation on breast cancer stage at diagnosis, race/ethnicity, and socioeconomic status. Methods. Eight electronic databases were searched using combination of key words. Of the 312 articles retrieved from the search, 36 studies from 12 countries were considered eligible for inclusion. Results. This review identified 17 (47%) of 36 studies in which breast cancer patients residing in geographically remote/rural areas had more late-stage diagnosis than urban women. Ten (28%) studies reported higher proportions of women diagnosed with breast cancer resided in urban than rural counties. Nine (25%) studies reported no statistically significant association between place of residence and stage at diagnosis for breast cancer patients residing in rural and urban areas. Conclusions. Cancer patients residing in rural and disadvantaged areas were more likely to be diagnosed with distant breast metastasis. Efforts to reduce these inequalities and subsequent mortality are needed.

The fertile social movements of the 1960s in the United States gave birth to the community health center model. During the past 50 years, health centers have emerged as a national primary care institution serving over 20 million of the nation's most vulnerable people. Founded on the shared health center mission and commitment to collective action, the Health Disparities Collaboratives (HDC) provided a cultural and social milieu for accelerated learning as well as a homegrown system and infrastructure for collaborative learning and improvement. Although the HDC only existed during the years from 1999-2006, they generated positive health outcomes and strengthened the capacity of health centers for quality improvement. After a description of the history and the characteristics of the HDC, six recommendations are presented for the re-design and implementation of a second-generation health center learning and improvement system.

Objective . Tooth decay is related to poverty, measured at individual and neighbourhood levels. It is however uncertain if living in an advantaged neighbourhood reduces tooth decay similarly in Australian Indigenous and non-Indigenous children. Methods . This study describes tooth decay by neighbourhood characteristics and Indigenous status, and examines inequalities by Indigenous status. Results . In deciduous dentition the percentage of children with tooth decay and untreated decay decreased on average 26% and 20% respectively in the non-Indigenous sample from poor to affluent neighbourhoods. In Indigenous children tooth decay and untreated decay decreased on average 6% and 8%, respectively, from poor to affluent neighbourhoods. Conclusion . While all children from affluent areas had less tooth decay, the gap between non-Indigenous and Indigenous children remained significant across neighbourhood characteristics. This suggests that both universal and targeted prevention programs should be considered for all Indigenous children irrespective of where they live.

American Indians and Alaska Natives (AI/AN) experience significant health disparities relative to the general U.S. population. In particular, oral diseases affect the majority of the AI/AN population and their prevalence is significantly greater than observed in other demographic sectors of the U.S. population. The reasons for these disparities are multiple but lack of access to dental care is clearly a contributing factor. The dentist-to-population ratio in many AI/AN communities is less than half the U.S. average. A solution has been developed in Alaska by AI/AN leaders: dental therapists, i.e., local people trained for two years to provide basic dental services. This solution is being fought by organized dentistry that sees the approach as an economic threat, but AI/AN organizations are committed to implementing this Native solution to their access problem. The Alaska experience indicates that access to oral health services can be improved through the addition of dental therapists to the dental team.

Aim. The aim of this study was to describe the impact of oral health conditions among a convenience sample of Indigenous Australian adults and compare findings with nationally representative data. Methods. Data were obtained from the Indigenous Oral Health Literacy Project (IOHLP) based in South Australia. Nationally representative data were obtained from the National Survey of Adult Oral Health (NSAOH). The impact of oral disease was measured using the shortened form of the oral health impact profile, OHIP-14. All data were standardised by age group and sex utilising Census data. Results. For each OHIP-14 measure the impact was greater for IOHLP participants. There was considerable variation in the degree of difference between IOHLP and NSAOH participants for individual OHIP-14 items. Conclusion. High levels of effects of oral health conditions were reported by rural-dwelling Indigenous adults. This may exacerbate the health and social disadvantage experienced by this marginalised group. Refereed/Peer-reviewed

Rural populations often face higher cancer rates and have lower cancer screening rates than urban populations. Screening disparities may be mediated by limited access to care, less knowledge of screening, and psychosocial factors. While the improved insurance rates and more comprehensive coverage under the Affordable Care Act may address some of these barriers, rural-urban disparities in cancer screening may not be fully attenuated. Faith-based interventions have been an effective approach to improving cancer screening among rural and underserved populations. Similarly, faith community nurses (FCNs) may be an effective agents for implementing evidence-based cancer screening strategies in rural communities. We provide a model for how FCNs standards of professional performance and practice can enable them to implement screening strategies. We also posit two recommendations of services that FCNs can provide to improve cancer screening in rural areas: educational messaging and patient navigation.

Purpose. We aimed to determine whether the association between late-stage cancer and American Indian/Alaska Native (AI/AN) race differed by enrollment in the Indian Health Service Care System (IHSCS). Methods. We used Surveillance, Epidemiology, and End Results (SEER) data linked to Medicare files to compare the odds of late-stage breast, colorectal, lung, or prostate cancer between non-Hispanic Whites (NHWs) (n=285,993) and AI/ANs with (n=581) and without (n=543) IHSCS enrollment. Results. For AI/ANs without IHSCS enrollment, the odds of late-stage disease were higher in AI/ANs compared with NHWs for breast (OR=3.17, 95%CI: 1.82–5.53) and for prostate (OR=2.59, 95%CI:1.55–4.32) cancer, but not for colorectal or lung cancers. Among AI/ANs with IHSCS enrollment, there was not a significant association between late-stage disease and AI/AN race for any of the four cancers evaluated. Conclusion. Our results suggest that enrollment in the IHSCS reduced the disparity between AI/ANs and NHWs with respect to late-stage cancer diagnoses.

Antihypertensive medication use protects against adverse health effects of hyper-tension. Residents of low-income urban communities are disproportionately Black and Latino, and may experience heightened cardiovascular health risks due to reduced medication use. We estimate the odds of antihypertensive medication use by race/ethnicity and socioeconomic position. Data are from the Healthy Environments Partnership Community Survey, restricted to 377 hypertensive participants. Antihypertensive medication use was defined as people with hypertension who were taking antihypertensive medication. Racial/ethnic and socioeconomic differences in medication use were examined using multivariate logistic regression. Odds of antihypertensive medication use were lower for people with incomes 1.00-1.99 times the poverty level (OR=0.75, p=.05) compared with those ≥2.00 times poverty, and for Latinos (OR=0.48, plt;.01) and Whites (OR=0.50, plt;.01) compared with Blacks. Findings suggest a need to improve hypertension screening and treatment for residents of low-to moderate-income urban communities, with attention to subgroups who may have limited health care access.

Summary: Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs) experi- ence a large burden from certain chronic disease- related risk factors. The STRIVE Program funded four AANHPI community- based organizations (CBOs) to implement culturally adapted community gardens and farmers' markets to increase access to healthy foods. Key CBO informant interviews were conducted to understand processes and lessons learned.

The study assessed whether children with special health care needs (CSHCN) living in Appalachian Ohio have differential health care utilization, unmet needs, and health outcomes compared with CSHCN in Ohio's metropolitan counties using a statewide Ohio survey. Based on this survey, an estimated 28% of children in Appalachian Ohio counties have special health care needs compared with 25% of children in metropolitan counties. In Appalachia, CSHCN are poorer and more likely to have Medicaid than their metropolitan counterparts, but had no reported significant differences in health outcomes or unmet needs. Data suggested a trend toward higher use of emergency department care and inpatient services and lower use of well-child visits but these differences did not reach significance. We conclude that CSHCN in Appalachian and metropolitan areas face similar levels of health status and unmet needs but results suggest a need for additional research on access to primary care services.

American Indians and Alaska Natives (AI/ANs) die from chronic liver disease at high rates, but little data exist on the etiology of liver disease in AI/ANs. Adult participants from a tribal health clinic in the Pacific Northwest completed an alcohol consumption survey and underwent laboratory testing, and anthropometric measurements. Participants with abnormal serum alanine aminotransferase (ALT) levels, positive hepatitis B surface antigen, or hepatitis C antibody were invited for follow-up visit. Then, they received a limited liver ultrasound, additional liver function tests, and confirmatory hepatitis tests. Among 71 participants, 26 (37%) had sustained elevation of ALT over six months. Two patients (8%) had chronic hepatitis C virus and 19 (73%) had ultrasonographic steatosis suggesting nonalcoholic fatty liver disease (NAFLD). Elevated aminotransferase levels were common, with NAFLD and hepatitis C accounting for most cases. Few participants were aware of their liver condition, indicating the need for increased awareness, screening, and intervention.

American Indian and Alaska Native (AI/AN) populations report poor physical and mental health outcomes while tribal health providers and the Indian Health Service (IHS) operate in a climate of significant under funding. Understanding how the Patient Protection and Affordable Care Act (ACA) affects Native American tribes and the IHS is critical to addressing the improvement of the overall access, quality, and cost of health care within AI/AN communities. This paper summarizes the ACA provisions that directly and/or indirectly affect the service delivery of health care provided by tribes and the IHS.

Objective . This study assessed the usefulness of the Healthy Weight Disparity Index (HWDI) to evaluate income disparities related to obesity. We compared state based body mass index (BMI) rankings with HWDI rankings. Methods . National data from the 2010 Behavioral Risk Factor Surveillance System were used to estimate mean BMI levels in each of the 50 states (plus Washington, D.C.) by income level. Income-related disparities were described with the HWDI. Kappa statistics analyzed the concordance between the two rankings. Results . State-based BMI and the HWDI rankings were not concordant. For example, Washington, D.C. was ninth for lowest mean BMI yet ranked 49th on the HWDI. West Virginia ranked 42nd and 5th, and Mississippi ranked 51st on both the BMI and HWDI, respectively. Discussion . State-based BMI and HWDI rankings present divergent perspectives on the obesity crisis. We recommend adding HWDI rankings to BMI rankings to reflect fully patterns of obesity and subgroup differences.

In what is known as Simpson's Paradox, a statistical association present within different groups becomes reversed when the groups are aggregated. Because race is con- founded with socioeconomic status (SES) in the U.S., the overall smoking rate among Blacks may exceed that among Whites, even while the reverse is true within SES strata (or when adjusting for SES). Indeed, in the most recent five iterations of the Behavioral Risk Factor Surveillance System (2008- 2012), a nationwide dataset, unadjusted models found that non- Hispanic Blacks were more likely than non- Hispanic Whites to report current smoking (e.g., in 2012: OR=1.14, p

In Tennessee, African Americans suffer significantly from infant morbidity, sexually transmitted diseases, and deaths from vascular disease and cancer. The Meharry Medical College Wellness Project addresses these health disparities with a service learning curriculum focused on community-based research. Trained minority undergraduates have conducted 355 Institutional Review Board-approved community intervention projects statewide.

Although invasive cervical cancer incidence has declined, disparities persist. We identified spatial clusters of census tracts with elevated invasive cervical cancer incidence rates using New Jersey State Cancer Registry cases 20 years or older diagnosed in 2005-2009. Each cluster's population was compared with the rest of New Jersey's population on demographic and socioeconomic characteristics. Odds ratios that assessed associations between statistically significant characteristics (from a univariate comparison of cases in the clusters versus cases in the rest of New Jersey) and being a case in a cluster versus being a case in the rest of New Jersey were calculated from logistic regression models. Significant incidence clusters were identified around Newark, Trenton, and Camden. Being Black (all areas), Hispanic (Newark, Camden), unmarried (Newark), and uninsured/Medicaid-insured (Trenton) were significantly associated with being a case in these areas. These study results can be used to target invasive cervical cancer prevention efforts more effectively.

Objectives . Develop and pilot test the Health in Community Survey (HCS), to collect patients’ perceptions of care integration between traditional care providers and community-based services that address social determinants of health. Research design . Interviews of working-age, English-or Spanish-speaking patients with multiple chronic conditions to identify survey domains; cognitive interviews and pilot test of HCS Version 1. Results . Preliminary interview subjects identified diverse care concerns. From these findings, we designed six HCS domains. Cognitive interviews identified problems relating to patients’ perceptions about limited function and disability. Nearly one-third of pilot test subjects reported they did not definitely have enough resources for food, transportation, doctor and hospital bills, and medications; 41.6% said their clinicians only sometimes or never knew about their resource problems. Conclusions . Although it requires further validation, the HCS offers insights into patients’ perceptions of care integration between traditional health care providers and services addressing social determinants of health.

This report is the outcome of an expert consensus meeting sponsored by the United States Deparment of Health and Human Services Office of Minority Health, which was convened to formulate consensus statements, provide recommendations and identify key strategies from practice for implementing integrated health and behavioral health care intended to improve health status for underserved populations.

Introduction . Hispanic women in Puerto Rico share health concerns that affect women generally, and suffer disproportionately from some health concerns relative to non-Hispanic women. The University of Puerto Rico Women’s Health Center contributes to the promotion of women’s health by developing sustainable preventive services, designing programs according to women’s needs, and creating awareness of sex/gender differences in health and disease. Initiatives . A longitudinal breast cancer early detection clinic was developed and a community screening campaign was coordinated. Focus groups were conducted. A course on sex/gender considerations in research was developed and offered. Outcomes . Access to early detection of breast cancer was provided through an annual on-campus clinic and a community screening campaign. A breast cancer support group resulted from focus group recommendations. Health professionals from diverse disciplines participated in a course on sex/gender considerations in research. Conclusions . Synergistic efforts towards eliminating disparities in women’s health from an academic perspective provide a valuable tool for the promotion of health among Hispanic women living in Puerto Rico.

For over two decades, a concerted effort has been underway to tackle health disparities. State Offices of Minority Health (OMH) have led efforts in data collection, training, and policy development. Yet, little evidence exists regarding the effectiveness of these efforts. I address this dearth of knowledge by examining the impact of state Offices of Minority Health on Black infant mortality rates. I perform a longitudinal regression analysis controlling for political, economic, and policy variables. I find that state OMHs are associated with a decrease in Black infant mortality rates. Furthermore, when Medicaid spending is low, the implementation of a state OMH decreases Black infant mortality over time. As Medicaid spending increases, however, the effect diminishes. State OMHs and Medicaid are important tools to decrease Black infant mortality rates. States that invest relatively little in health care for the poor should consider increasing investments in their Offices of Minority Health.